Download Orthognathic surgery refers to the surgical correction of

Medical Coverage Policy | Orthognathic Surgery
EFFECTIVE DATE: 06/01/2015
POLICY LAST UPDATED: 05/19/2015
OVERVIEW
Orthognathic surgery refers to the surgical correction of abnormalities of the maxilla, mandible, or both. This
policy is not applicable to BlueCHiP for Medicare members.
MEDICAL CRITERIA
Commercial
Orthognathic surgery is considered medically necessary when any of the following facial skeletal deformities
are present:
1. Anteroposterior discrepancies:
 Maxillary/mandibular incisor relationship: overjet of 5mm or more, or a 0 to a negative value
(norm 2mm); or
 Maxillary/mandibular anteroposterior molar relationship discrepancy of 4mm or more (norm 0
to 1mm). (These values represent two or more standard deviations from published norms.*)
2. Vertical discrepancies:
 Presence of a vertical facial skeletal deformity that is two or more standard deviations from
published norms for accepted skeletal landmarks; or
 Open bite:
o No vertical overlap of anterior teeth; or
o Unilateral or bilateral posterior open bite greater than 2mm
 Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing
arch; or
 Supraeruption of a dentoalveolar segment due to lack of occlusion.
3. Transverse discrepancies:
 Presence of a transverse skeletal discrepancy that is two or more standard deviations from
published norms; or
 Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4mm or greater, or a
unilateral discrepancy of 3mm or greater, given normal axial inclination of the posterior teeth.
4. Asymmetries:
 Anteroposterior, transverse, or lateral asymmetries greater than 3mm with concomitant occlusal
asymmetry.
* “Published norms” available from Surgical Correction of Dentofacial Deformities by Epker, Fish & Stella and
Contemporary Treatment of Dentofacial Deformity by Proffit, Sarver & White.
Required Documentation
The following clinical documentation is required to determine medical necessity for orthognathic surgery:
 Photos for both frontal and profile smiling
 Presurgical frontal and lateral cephalograms
 Panoramic film
 Consultation letter (diagnostic/treatment plan)
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
Prediction tracing using presurgical cephalogram
The required documentation (photos, cephalogram, panoramic film, consultation letter, prediction tracing)
must be completed within six (6) months of submitting the case for review.
PRIOR AUTHORIZATION
BlueCHiP for Medicare
Not applicable
Commercial Products
Prior authorization is recommended for Commercial products and obtained via the online tool for
participating providers. See the Related Policies section.
POLICY STATEMENT
BlueCHiP for Medicare
Orthognathic surgery is not covered for BlueCHiP for Medicare members as CMS considers these
procedures to be dental and dental services are not covered.
Commercial Products
Orthognathic surgery is considered medically necessary when the severity of the skeletal deformity results in
significant functional impairment and the deformity cannot be adequately treated through dental or
orthodontic services alone when medical criteria are present.
An orthognathic case involves essentially four phases:
Phase 1: Pre-operative (Noncovered*)
This is a monitoring and work-up phase, which can last 1-3 years depending on the complexity of the
case. The oral surgeon is monitoring the patient during orthodontic treatment/growth to determine
the correct timing for the surgery.
Phase 2: Pre-operative Records/Stabilization (Noncovered*)
As the date for surgery gets closer, the surgeon must perform model surgery, tracings of the pre- and
post-op results, and fabrication of the fixation devices that will stay in the patient’s mouth for
approximately 6-8 weeks after surgery. This is all accomplished outside of patient office visits.
Phase 3: Surgery (Covered with prior authorization)
The surgical procedure of jaw movement and fixation in the hospital setting is performed. The
patient usually has a 3-5 day hospital stay. A 90-day post-operative period is included in this fee.
Phase 4: Post-op After 90 Days (Noncovered*)
The oral surgeon continues to monitor the patient for a period of 1-3 years following the surgical
phase.
Under BCBSRI policy, the surgery (phase 3) with preauthorization is a covered benefit and reimbursed by
Blue Cross medical coverage.
*The pre-operative phase (phase 1), pre-operative records/stabilization (phase 2), and post-op after 90-days
(phase 4) are not covered benefits under the member’s medical or BCBSRI dental plan. The services
performed in phases 1, 2, and 4 are the member’s responsibility. The fee for phases 1, 2, and 4 is determined
by the oral surgeon prior to surgery and is dependent on the complexity of the case. It is the surgeon’s
responsibility to discuss the fee with the patient prior to surgery.
The following are considered contract exclusions when performed in conjunction with orthognathic surgery
for the sole purpose of improving patient appearance:
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Rhinoplasty for nose reshaping
Osteoplasty for facial bone reductions for cosmetic reasons
Genioplasty to improve the appearance of the chin
Rhytidectomy (face-lift)
COVERAGE
Benefits may vary between groups and/or contracts. Please refer to the appropriate evidence of coverage,
subscriber agreement, or member certificate for the applicable surgery benefits/coverage.
BACKGROUND
Orthognathic surgery refers to the surgical correction of abnormalities of the maxilla, mandible, or both. The
underlying abnormality may be present at birth or may become evident as the patient grows and develops or
may be the result of traumatic injuries, systemic conditions, or environmental influences. Surgery is generally
performed when the severity of the skeletal deformity results in significant functional impairment and the
deformity cannot be adequately treated through dental or orthodontic services alone. Examples of conditions
that could require orthognathic surgery are mandibular prognathism, crossbite, open bite, overbite, underbite,
mandibular deformity, and maxillary deformity. The goal of treatment is to improve function through
correction of the underlying dentoskeletal deformity.
Correcting this dentoskeletal deformity through orthognathic surgery requires comprehensive preoperative
planning and coordination with other dentists and dental specialists. An oral and maxillofacial surgeon or
plastic and reconstructive surgeon performs the surgery itself. Due to its complexity, precision, and duration,
it often requires two surgeons. The surgery involves cutting the maxilla (upper jaw) or mandible (lower jaw)
or both. The bones are then realigned to achieve goals such as normalized occlusion, relief of pain, improved
chewing, swallowing, and speech.
The American Association of Oral and Maxillofacial Surgeons (AAOMS) believes orthognathic surgery is
supported by clinical evidence for specific conditions. These include the treatment of maxillary and/or
mandibular facial skeletal deformities associated with masticatory maloccusion such as specific
anteroposterior, vertical transverse discrepancies, and asymmetries.
Orthognathic surgery in the absence of significant physical functional impairment is considered cosmetic and
not medically necessary.
Augmentation, such as implants, to reshape or enhance parts of the face is considered not medically
necessary when performed in conjunction with orthognathic surgery for the sole purpose of improving
patient appearance.
CODING
Commerical Products
The following codes are covered when medical criteria has been met:
21141 Reconstruction midface, LeFort I; single piece, segment movement in any direction (e.g., for Long
Face Syndrome), without bone graft
21142 Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft
21143 Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without
bone graft
21145 Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone
grafts (includes obtaining autografts)
21146 Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone
grafts (includes obtaining autografts) (e.g., ungrafted unilateral alveolar cleft)
21147 Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring
bone grafts (includes obtaining autografts) (e.g., ungrafted bilateral alveolar cleft or multiple
osteotomies)
21150 Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins Syndrome)
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21151 Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining
autografts)
21154 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining
autografts); without LeFort I
21155 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining
autografts); with LeFort I
21159 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (e.g., mono
bloc), requiring bone grafts (includes obtaining autografts); without LeFort I
21160 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (e.g., mono
bloc), requiring bone grafts (includes obtaining autografts); with LeFort I
21188 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining
autografts)
21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft
21194 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes
obtaining graft)
21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation
21196 Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation
21198 Osteotomy, mandible, segmental
21199 Osteotomy, mandible, segmental; with genioglossus advancement
21206 Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)
21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)
21209 Osteoplasty, facial bones; reduction
21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts)
(e.g., for hemifacial microsomia)
RELATED POLICIES
Preauthorization via Web-Based Tool for Procedures
PUBLISHED
Provider Update July 2015
Provider Update January 2015
Provider Update, February 2014
Provider Update, March 2012
Provider Update, February 2009
Policy Update, October 2007
REFERENCES
1. Lucille Packard Children's Hospital at Stanford: Craniofacial Anomalies: Orthognathic (Maxillofacial) Facial
Surgeryhttp://www.lpch.org/DiseaseHealthInfo/HealthLibrary/craniofacial/maxface.html
2. American Association of Oral and Maxillofacial Surgeons: Coding for Orthognathic Surgery.
Retrieved on 4/16/2007 from
hhttp://www.aaoms.org/docs/practice_mgmt/coding_papers/orthognathic_surgery.pdf
3.J Oral Maxillofacial Surg. 2003 Jun; 61 (6): 655-61. Wolford, LM, Reiche-Fischel O., Mehra P. Changes in
temporomandibular joint dysfunction after orthognathic surgery. Retrieved on 4/30/2007 from
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12796870&dopt=
Citation
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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical
judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate
and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific
benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases
medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the
member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation
agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge
are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue
Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.
500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699
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